This information is not a replacement for medical care nor is it intended to be a substitute for advice from your physician or other qualified
|
|
- Magdalen Wright
- 8 years ago
- Views:
Transcription
1 Low Back Pain Clinical Improvement Team Final Report January 2007 This information is not a replacement for medical care nor is it intended to be a substitute for advice from your physician or other qualified medical professional.
2 Low Back Pain Clinical Improvement Team Final Report - Table of Contents Section Page Executive Summary Final Report: I. Background II. Defining the Problem III. The Back Pain Clinical Improvement Team IV. Area of Focus and Objectives V. Recommendations: A. Treatment of Low Back Pain During the First Six Weeks 11 B. Preventing Acute Back Pain from Becoming Chronic VI. Review of Evidence-Based Clinical Guidelines VII. Recommended Performance Measures VIII. Recommended Change Strategies Appendix I: Members of the Back Pain Clinical Improvement Team 33 Appendix II: Definition of Key Terms 34 Appendix III: Sample Imaging Checklist 35 Appendix IV: Sample Return-to-Activity Coaching Form 36 Page 1 of 36
3 Low Back Pain Clinical Improvement Team Executive Summary December 2006 The Puget Sound Health Alliance s Low Back Pain Clinical Improvement Team (CIT) was convened in March 2006 to: (1) identify standardized clinical guidelines and performance measures, and (2) identify practical strategies to influence preferences, choices, and processes regarding appropriate prevention, treatment and self-management of low back pain. Low back pain was identified as a high priority condition, since it is a leading cause of work-related disability and workers compensation for people under age 45, affecting about two-thirds of all adults at some point in time. Even though initial episodes of acute low back pain are likely to improve within six weeks without medical intervention, a substantial portion of people with low back pain will go on to have more persistent back problems. Medical costs associated with back pain are in excess of $25 billion per year, and employers face huge costs in lost productivity and disability payments. In the early 1990s, the U.S. had the highest rate of spine surgery of all industrialized nations, with a rate five times that of Great Britain. The Low Back Pain CIT consisted of community members, representing clinical specialists, complementary and alternative medicine practitioners, patients, purchasers, health plans, and clinical researchers. The members met six times from March through October of The Low Back Pain CIT chose to limit its focus to acute axial low back pain without radiculopathy, with an emphasis on preventing acute pain from becoming chronic. The CIT s recommendations do not apply to more serious conditions that are indicated by certain red flags. The CIT chose to focus its work on workingage adults who are commercially insured who receive services or care for low-back pain in outpatient settings, with an emphasis on primary care. The CIT chose not to endorse a specific clinical guideline for low back pain, as many are not up-to-date for the primary management of back pain. However, the proposed National Committee for Quality Assurance (NCQA) Spine Care Recognition Program was identified as a high quality framework for the CIT s recommended performance measures and change strategies. Once finalized, the proposed NCQA Spine Care Recognition Program will likely be regarded as a high quality set of standards and measures. The CIT members agreed on several quality improvement recommendations for providers and patients, which are consistent with a conservative Low Back Pain CIT Final Report January 2007 Page 2 of 37
4 approach to the treatment of low back pain during the first six weeks. The CIT s recommendations for improvement fall into two categories: (a) treatment of low back pain during the first six weeks, and (b) preventing acute back pain from becoming chronic. Recommendations for the treatment of low back pain during the first six weeks include: 1. All patients presenting with low back pain should have a complete assessment to determine whether there are any red flag conditions. 2. In the absence of red flag conditions, patients should be thoroughly assessed for history of back pain and responsiveness to therapy during any previous episodes. 3. In the absence of red flag conditions, imaging should not be done during the first six weeks following the onset of acute axial low back pain. 4. Surgery in the first six weeks in the absence of red flags or progressive symptoms is not recommended. 5. Generally, providers should follow a conservative approach to treatment of low back pain during the first six weeks (when red flag conditions are not present), with the goal of preventing re-injury. Recommendations for preventing acute back pain from becoming chronic include: 1. Providers should assess all patients with low back pain for emotional status and work-life issues, provide reassurance to reduce fear and anxiety, and promote active self-management. 2. In the absence of red flag conditions, bed rest is not recommended and patients should be advised to remain active, returning to normal activity as soon as possible. 3. Patients with back pain who smoke should be assisted with smoking cessation. 4. Patients with low back pain should be assessed for functional status, using commonly available tests (such as the SF-36 or SF-12 Health Survey). The CIT agreed upon the use of two clinical performance measures to determine the rates of unnecessary imaging and unnecessary surgery within six weeks after the first visit. In order to remain consistent with national efforts, the Alliance will initially use the corresponding NCQA-HEDIS measures in the performance reports. The Back Pain CIT concluded its work by developing specific change strategies and tools to guide stakeholders in implementing the recommendations. The CIT agreed that preventing unnecessary imaging would have one of the largest impacts on improving the quality and reducing the cost of back pain management. Low Back Pain CIT Final Report January 2007 Page 3 of 37
5 Low Back Pain Clinical Improvement Team Final Report December 2006 I. Background In December 2003, King County Executive Ron Sims convened a broad-based leadership group, The King County Health Advisory Task Force, to develop an integrated strategy to address the systemic problems facing the health care system in the Puget Sound region. In particular, Executive Sims requested that the Task Force focus on three inter-related issues: the increase in health care costs for employees and employer purchasers, quality of care, and the importance of improving the health of the community. 1 The Task Force described the current system of health care as a series of disconnected strategies all working concurrently but without a system steward, or neutral leader, to coordinate them and ensure that they are achieving the optimal mix of cost, quality, and health outcomes. 1 As part of their recommendation to develop an integrated strategy, the Task Force advised creating a regional partnership to provide the necessary leadership to forge changes in the existing system. The Puget Sound Health Alliance (the Alliance) was created to fill this role, with the bold vision to develop a state-of-the-art health care system that provides better care at a more affordable cost, resulting in healthier people in the Puget Sound Region. Its mission is to build a strong alliance among patients, doctors and other health care providers, hospitals, employers and health plans to promote health and improve quality and affordability by reducing overuse, under-use and misuse of health services. The Alliance, in existence since 2005, has developed an extensive membership of providers, employer/purchasers, hospitals, health care associations, health plans and individual consumers in a five county region in northwest Washington composed of Snohomish, King, Kitsap, Pierce and Thurston counties. 1 King County Health Advisory Task Force Final Report, June 2004 [Accessed online November 7, 2006, Low Back Pain CIT Final Report January 2007 Page 4 of 37
6 The Alliance and its participants support the use of evidence to identify, measure, and report on the quality, cost, and patient experience in local health care. The Alliance will identify and recommend practical strategies to change preferences, choices, and processes regarding appropriate prevention, treatment and self-management of chronic diseases. The changes that the Alliance will recommend are intended to align incentives so that everyone involved -- patients, employers and other purchasers, providers, hospitals, health plans, and companies that produce or offer health care services or products -- is more likely to engage in activities that promote good health, reduce waste, and improve the affordability of health care. At the June 2005 Alliance Board meeting there was consensus among Board members that the Alliance would initially focus on four conditions: heart disease, diabetes, low back pain and depression. Later, prescription drugs was added as a fifth area of focus. Clinical Improvement Teams (CITs) for each clinical priority have been formed. The CITs report to the Quality Improvement Committee and develop recommendations to the Board on evidence-based guidelines, performance metrics and measurement approaches, and implementation strategies for quality improvement in each area. II. Defining the Problem: Low Back Pain A. General Low back pain is a leading cause of work-related disability and workers compensation for people under age 45, affecting about two-thirds of all adults at some point in time. 2 Low back pain commonly occurs between the ages of 35 to Unlike conditions such as diabetes or heart disease, back pain is not a condition with one or two specific causes and a well-defined set of signs and symptoms. Low back pain may be caused by systemic conditions such as osteoporosis, cancer, or anatomic problems such as fracture, but the vast majority of low back pain cannot be identified as having a single pathophysiologic cause. Such nonspecific back pain occurs in approximately 85 percent of patients with back pain. 4 The human response to pain is to seek relief and to try to fix the condition causing the problem. There are now available numerous technologies and procedures to locate, diagnose and treat a wide variety of problems, and practitioners are expected to use any available resource and the newest technology to relieve the pain and fix the problem. However, there is evidence 2 Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): [Andersson GBJ. Epidemiologic features of chronic low back pain. Lancet. 1999;354: ] 3 Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006; 15: Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Low Back Pain CIT Final Report January 2007 Page 5 of 37
7 that approximately 90 percent of nonspecific low back pain improves within six weeks without medical intervention or management. 5 Even though initial episodes of acute back pain are likely to improve, a substantial portion of people with low back pain will go on to have more persistent back problems, chronic recurrences, or continuous pain of varying or constant intensity. 6,7 These recurrences of acute back pain are estimated to affect 40 percent of patients within six months 8 and 50 to 80 percent of patients within one year. 9 While only two to seven percent of acute back pain sufferers actually develop chronic pain, 10 recurrences of acute pain may lead patients to perceive that they have a chronic condition, analogous to asthma, which will continue indefinitely without intervention. 11 Many patients expect that every available resource and new technology ought to be used and these expectations have led to an overuse of available resources and high costs. Back pain is the most expensive cause of work-related disability. 12 The medical costs associated with back pain are in excess of $25 billion per year, and employers also face huge costs in lost productivity and disability payments. 13 Low back pain costs $50 billion to as high as $100 billion annually in direct medical and indirect costs. 14 Patients with back pain seek relief from a wide variety of practitioners, including primary care physicians, surgeons, physical therapists, chiropractors, osteopaths, and others. Similarly, treatments for low back pain vary widely and include but are not limited to spinal mobilization, exercise, massage, acupuncture, ergonomics, and electromyographic biofeedback. Because of the wide range of providers and therapies available for the management of back pain, programs aimed at educating consumers, promoting consistency in the delivery of back pain-related care, and promoting quality care are difficult to plan and administer. Traditionally the emphasis has been on determining the pathophysiology or systemic cause of a patient s back pain, usually with the use of imaging tests. However, studies have shown that many of the abnormalities shown on imaging tests and previously thought to be the cause of patients back pain 5 Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006; 15: Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ May 2;316(7141): Von Korff M. Studying the natural history of back pain. Spine Sep 15;19(18 Suppl):2041S- 2046S. 8 Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006;15: Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006;15: Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): [Andersson GBJ. Epidemiologic features of chronic low back pain. Lancet. 1999;354: ] 13 Frymoyer JW, Cats-Baril WL. Orthop Clin North Am Apr;22(2): Frymoyer JW, Cats-Baril WL. Orthop Clin North Am Apr;22(2): Low Back Pain CIT Final Report January 2007 Page 6 of 37
8 (such as annular tears and disc bulges) are in fact common findings in individuals without low back pain. 15, 16, 17 While some anatomic findings, such as moderate to severe central stenosis, nerve root compression, and disc extrusions, are likely associated with current pain, studies have found that factors such as depression are more important predictors of new back pain than many of the anatomic abnormalities found on imaging tests. 18 In the early 1990s, the U.S. had the highest rate of spine surgery of all industrialized nations with a rate five times that of Great Britain. 19 Spine surgery has increased steadily during the past decade, and Medicare spending for inpatient spine surgery has more than doubled during that time. 20 Though spending for lumbar discectomy and laminectomy declined by more than 10 percent, spending for lumbar fusions increased more than 500 percent during the past decade, reaching $482 million in In 1992, lumbar fusions accounted for 14 percent of total spending for spine surgery; by 2003, they represented 47 percent. 21 B. Washington State The prevalence of back pain and its associated costs in Washington are difficult to determine as back pain has no consistent presentation and cause. Nonwork-related back pain is not a reportable condition, nor is there a registry of patients with back pain. For work-related injuries, surveillance data from the Washington State Department of Labor and Industries for show that, of the 354,770 State Fund accepted claims for work-related musculoskeletal disorders of the neck, back and upper extremity, 52.6 percent were claims for back disorders Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Jordan J, Konstantinou K, Morgan TS, Weinstein J. Herniated lumbar disk. Clin Evid Concise 2006;15: Patel AT and Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician 2000;61: , Jarvik JG, Hollingworh W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: Clinical and imaging risk factors. Spine 2005;30(13): Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain. Ann Intern Med. 2003;138(11): Dartmouth atlas of health care. Spine surgery: A report by the Dartmouth Atlas of Health Care CMS- FDA Collaborative Dartmouth atlas of health care. Spine surgery: A report by the Dartmouth Atlas of Health Care CMS- FDA Collaborative Silverstein B and Adams D. Work-related musculoskeletal disorders of the neck, back, and upper extremity in Washington state, Technical Report Number SHARP Program, Washington State Department of Labor and Industries. December Low Back Pain CIT Final Report January 2007 Page 7 of 37
9 State and local spine surgery rates are available through the Dartmouth Atlas Project which provides ongoing population-based monitoring of rates in the feefor-service Medicare population. 23 The Dartmouth Atlas Project (DAP) focuses on data collected by the Centers for Medicare and Medicaid Services (CMS) for every person and provider using Medicare health insurance, a uniform national claims database available for research purposes. There is no counterpart to this database for the commercially insured population. However, similar studies done by the DAP using state all-payer data in Pennsylvania and Virginia, and Blue Cross Blue Shield data in Michigan, have shown similar variations among the under-65 population. 24 Dartmouth Atlas Project data show that there is considerable regional variation in surgery rates. The national average rate of spine surgery was 4.0 per 1,000 in 2003, ranging from 1.6 per 1,000 enrollees to 9.4. Washington had the 14 th highest back surgery rate of all states and the District of Columbia, with a back surgery rate of 4.85 per 1,000 Medicare enrollees. 25 The Seattle Hospital region had a spine surgery rate of 4.27 per 1,000 Medicare enrollees compared to a U.S. rate of Seattle s lumbar discectomy/laminectomy rate per 1,000 Medicare enrollees was 2.66 compared to a U.S. rate of 2.13, while the lumbar fusion rate was 0.85 per 1,000 enrollees compared to a U.S. rate of III. The Low Back Pain Clinical Improvement Team The Low Back Pain Clinical Improvement Team (CIT) members represented primary care providers of various types, surgeons, health plans, purchasers, and consumers. The members of the Low Back Pain CIT are listed in Appendix I. 23 Dartmouth Atlas of Health Care. Spine surgery: A report by the Dartmouth Atlas of Health Care CMS- FDA Collaborative Dartmouth Atlas of Health Care. Frequently Asked Questions. Accessed online: October 18, Dartmouth Atlas of Health Care: Data tables Dartmouth Atlas of Health Care. Spine surgery: A report by the Dartmouth Atlas of Health Care CMS- FDA Collaborative. Low Back Pain CIT Final Report January 2007 Page 8 of 37
10 IV. Area of Focus and Objectives A. Disease Scope The Low Back Pain CIT chose to limit its focus to acute * axial * low back pain without radiculopathy, * with an emphasis on preventing acute pain from becoming chronic, and excluding cancer, traumatic fracture, osteomyelitis, * and other pathophysiologic conditions. The intent of the recommended disease scope is to include acute low back pain involving the trunk and lasting up to six weeks duration that results from mechanical or behavioral processes, and to exclude low back pain accompanied by pain radiating down the legs, chronic * pain, and pain resulting from malignancy, fracture, and other pathophysiologic conditions. The CIT noted that while the natural history of back pain with radiculopathy is similar to that of back pain without radiculopathy, the prognosis and treatment options are different and potentially more complex. Therefore, radiculopathy was determined to be outside the scope of these recommendations. The presence of certain signs and symptoms in a patient with back pain increases the likelihood that the back pain results from a distinct pathophysiologic condition that may require prompt evaluation and treatment. These signs and symptoms are commonly known as red flags or red flag conditions, and patients with red flag conditions are excluded from the scope of this report. Red flag conditions include the following: Red Flag Conditions (Excluded from CIT s Disease Scope) Back pain of more than six weeks duration not responding to conservative care Neurogenic claudication [Leg pain that mimics arterial claudication. Usually refers to intermittent cramping pain and weakness in the legs and especially the calves on walking that disappears after rest.] Saddle anesthesia [Numbness in the perineal area]] Recent onset of urinary retention, increased frequency, overflow Bowel incontinence * acute duration of six weeks or less * axial pertaining to the trunk * radiculopathy a pathologic condition affecting the nerve roots, also refers here to pain extending beyond the trunk * osteomyelitis inflammation of the bone marrow * chronic lasting greater than six weeks Low Back Pain CIT Final Report January 2007 Page 9 of 37
11 Severe or progressive neurological deficit in the lower extremity [Severe or progressive weakness or changes in sensation in the legs] Upper motor neuron findings [suggesting cerebral cortex or spinal cord involvement] Major trauma [e.g., motor vehicle accident, fall from height] Minor trauma or strenuous lifting in a person age less than 20 yrs. or greater than 70 yrs. or with osteoporosis Possible tumor History of cancer Constitutional symptoms [e.g., recent fever, chills, unexplained weight loss] Risk factors for spinal infection [e.g., recent bacterial infection such as urinary tract infection intravenous drug abuse; immune suppression as a result of steroid use, transplant, HIV, etc.] Pain that worsens when supine [when lying on the back] Severe nighttime pain Additional terminology can be found in Appendix II. B. Target Population The Low Back Pain CIT chose to focus its work on working age adults who are commercially insured. It was agreed that an age range helps define the focus but it was felt that a specific age range (e.g. age years) may be too limiting. In many cases, the age of the patient does not affect the diagnosis or treatment. However, co-morbidity issues do increase with age as may the number of red flag conditions. Therefore, it was agreed that the focus should be on working age adults with the additional comment that these recommendations could apply outside that age range if co-morbidity related issues are taken into account. C. Setting The Low Back Pain CIT chose to focus on outpatient management of low back pain, with an emphasis on the primary care setting. Low Back Pain CIT Final Report January 2007 Page 10 of 37
12 V. Recommendations for Improvement A. Treatment of Low Back Pain During the First Six Weeks At the outset of their work, the CIT members agreed on several key quality improvement recommendations aimed at providers and patients, which are consistent with a conservative care approach to the treatment of low back pain during the first six weeks. Recommendations: 1. All patients presenting with low back pain should have a complete assessment to determine whether there are any red flag conditions. 2. In the absence of red flag conditions, patients should be thoroughly assessed for history of back pain and responsiveness to therapy during any previous episodes. 3. In the absence of red flag conditions, imaging should not be done during the first six weeks following the onset of acute axial low back pain. 4. Surgery in the first six weeks in the absence of red flags or progressive symptoms is not recommended. 5. Generally, providers should follow a conservative approach to treatment of low back pain during the first six weeks (when red flag conditions are not present), with the aim of preventing re-injury and changing behavior. A conservative approach should: a. Advise patients to remain active and return to normal activities as soon as possible. b. Evaluate patients for emotional status and work-life issues, and promote active self-management. c. Attempt a course of non-invasive treatment before considering costly interventions (such as MRIs or surgery) that, in the absence of certain defined conditions, have not been shown to improve patient outcomes. d. Avoid imaging. Explanation: The conservative approach to treatment of low back pain has been clearly defined by organizations such as the Institute for Clinical Systems Improvement (ICSI). The priority aims of ICSI s guideline align with the overarching recommendations of the Alliance s Clinical Improvement Team. Low Back Pain CIT Final Report January 2007 Page 11 of 37
13 For example, ICSI aims to increase the use of the recommended conservative approach as first-line treatment such as activity, self-care and analgesics for patients with low back pain. 27 ICSI also aims to reduce unnecessary imaging studies in patients with acute low back pain. 28 The algorithm included on page 13 is from ICSI s Adult Low Back Pain Health Care Guideline and is an excellent example of a conservative approach. 29 Preventing Unnecessary Imaging Preventing unnecessary imaging was identified as one of the single most important areas where simple behavioral changes could make a huge difference in how back pain is managed and in the costs associated with the management of back pain. There is no evidence that imaging is needed in patients with acute back pain of less than six weeks duration unless history and physical examination suggest underlying systemic disease or neurologic involvement. 30 When imaging is done prematurely [possibly at the insistence of the patient] incidental findings may lead to inaccurate diagnosis, increased patient anxiety, and unnecessary tests or treatment. 31 In patients with history or examination findings suggesting underlying systemic disease or neurologic involvement, or with persistent pain that does not improve with conservative therapy, plain radiographs (x-rays) and a normal erythrocyte sedimentation rates and/or c-reactive protein are recommended tests to evaluate for systemic disease while CT or MRI can be considered for persistent sciatica (pain along the sciatic nerve) or symptoms of spinal stenosis (narrowing of the lumbar spinal column that produces pressure on the nerve roots) The Institute for Clinical Systems Improvement. Adult Low Back Pain Guideline. Released September Accessed online October 17, Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. 28 The Institute for Clinical Systems Improvement. Adult Low Back Pain Guideline. Released September Accessed online October 17, Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. 29 The Institute for Clinical Systems Improvement. Adult Low Back Pain Guideline. Released September Accessed online October 17, Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. 30 Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Jarvik JG and Deyo RA. Diagnostic evaluation of low back pain with emphasis on imaging. Ann Intern Med 2002;137: Low Back Pain CIT Final Report January 2007 Page 12 of 37
14 Low Back Pain CIT Final Report January 2007 Page 13 of 37
15 A comparison of international guidelines on the management of low back pain concludes that, for the diagnosis of low back pain, work-up should include diagnostic triage. 33 Diagnostic triage includes history and physical exam to determine if any red flag conditions are present and evaluation of patients emotional status and presence of work-life issues, stress, and anxiety. 34 Plain radiographs (x-rays) are recommended only in patients with suspected underlying pathologic changes (red flag conditions) and imaging may be considered in patients with persistent low back pain lasting longer than six weeks. 35 U.S. and U.K. guidelines specifically advise against imaging for acute, nonspecific low back pain in the absence of red flag conditions. 36 Imaging guidelines from the American College of Radiology (ACR) were reviewed to see if they could be endorsed as a guide to help reduce unnecessary imaging in patients with back pain. 37 However, the ACR guidelines only look at applicability of different imaging techniques for certain conditions. They also were not evidence-based; they were developed through an informal process of consensus, and did not take costs into account. Most guidelines do not recommend a scan within the first six weeks of onset of back pain if red flag conditions are absent. However, expert members of the CIT estimated that currently up to 40 percent of patients with low back pain without red flag conditions receive an MRI within the first six weeks of diagnosis. The CIT agreed that the presence or absence of red flag conditions could be used as a primary indicator for when imaging is or is not appropriate. Red flag conditions are well-established, should be well-publicized, and their use in determining the suitability of imaging encouraged through incentives. Disincentives to discourage the ordering of inappropriate scans should also be considered. Imaging is frequently used to help place epidural injections in patients with pain. However, epidural injections (and the imaging tests that go with it) are not recommended in patients with acute low back pain during the first six weeks as there is good evidence that 90 percent of nonspecific back pain improves within six weeks without medical intervention or management Koes BW, van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: An international Comparison. Spine 2001;26(22): Koes BW, van Tulder MW, Ostelo R, Kim BA, Waddell G. Clinical guidelines for the management of low back pain in primary care: An international Comparison. Spine 2001;26(22): Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Koes BW, van Tulder MW, et al. Clinical guidelines for the management of low back pain in primary care: an international comparison. Spine 2001;26: ] 37 American College of Radiology (ACR) Appropriateness Criteria Acute Low Back Pain Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006;15: Low Back Pain CIT Final Report January 2007 Page 14 of 37
16 Also, there is no evidence that epidural injections are effective in patients with acute low back pain in the absence of radiculopathy. 39 Preventing Unnecessary Surgery Preventing unnecessary surgery was another area identified where behavioral changes could have an impact, as the majority of non-specific low back pain improves on its own within six weeks. There is no evidence from clinical trials or cohort studies that surgery is effective for patients who have low back pain unless they have sciatica [pain along the course of a sciatic nerve especially in the back of the thigh], pseudoclaudication [cramping and weakness], or spondylolisthesis [forward displacement of a lumbar vertebra on the one below it]. 40 These conditions are indicated by specific red flags. Only about 10 percent of patients with herniated discs have sufficient pain after six weeks to make surgery a consideration. 41 Studies have indicated no clear advantage for surgery, and comparisons of conservative and surgical treatment outcomes in patients with back pain have found that the outcomes appear to be roughly equivalent. 42 Patients with herniated discs as the specific cause of their back pain and who undergo surgery, do not return to work more quickly than those receiving conservative therapy, though they may have better symptomatic and functional outcomes. 43 There are also various risks and costs associated with back surgery. There are risks associated with the procedure itself, such as infection or spinal cord damage, and risks associated with anesthesia such as poor oxygenation, brain damage, and reactions to anesthetic agents. There are also the risks that the surgery may not be effective or have the desired outcome. According to the Washington State Department of Labor and Industries, a recent review of department data documented that 68 percent of workers with occupational low back pain conditions undergoing lumbar fusion surgery remained off work two years after surgery. 44 Costs associated with surgery include hospital costs and costs associated with rehabilitation from surgery. Among international guidelines there appears to be consensus that unless patients have progressive neurologic deficits requiring immediate surgical evaluation, most low back pain should be managed in a primary care setting 39 Koes B and van Tulder M. Low back pain (acute). Cin Evid Concise 2006;15: Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Patel AT and Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician 2000;61: , Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): Franklin GM, Haug J, Heyer NJ, McKeefrey SP, Picciano JF. Outcome of lumbar fusion in Washington State workers compensation. Spine. 1994;19(17): Low Back Pain CIT Final Report January 2007 Page 15 of 37
17 with referral to a specialist if red flag conditions are present 45 or if a conservative care approach has been tried and has failed. Conservative care approaches may include but are not limited to pharmacologic therapy, activity modification, massage therapy, acupuncture, physical therapy modalities such as ultrasound, exercise, patient education, and consideration of coping styles and work-life issues such as stress, fear, frustration and anger. 46 B. Preventing Acute Back Pain from Becoming Chronic A second area of focus, preventing acute back pain from becoming chronic, encompasses a range of approaches to back pain management that in the long term could decrease the incidence of back pain and its recurrence and cost. Even though initial episodes of acute back pain are likely to improve, a substantial fraction of persons will go on to have more persistent back problems, recurrent back pain, or continuous pain of varying or constant intensity. 47, 48 While only five percent of people with back pain are temporarily or permanently disabled, these patients account for 75 percent of the costs of back pain management. 49 One of the strongest predictors of onset of low back pain and of the transition from an acute episode of low back pain to chronic low back pain is the patient s emotional status and the presence of work-life issues. These issues strongly predict both long- and short -term disability events, duration, and health-care visits for low back pain problems. 50 Studies have shown that factors such as attitude, fear, depression, anxiety, distress, and related emotions are strongly associated with reported onset of back pain and are clearly linked to the transition from acute to chronic pain disability. 51 A purely biomedical approach may miss these important factors in the treatment of low back pain. 45 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Koes BW, van Tulder MW, et al. Clinical guidelines for the management of low back pain in primary care: An international comparison. Spine 2001;26: ] 46 Patel AT and Ogle AA. Diagnosis and management of acute low back pain. Am Fam Physician 2000;61: , Croft PR, Macfarlane GJ, Papageorgiou AC, Thomas E, Silman AJ. Outcome of low back pain in general practice: a prospective study. BMJ May 2;316(7141): Von Korff M. Studying the natural history of back pain. Spine Sep 15;19(18 Suppl):2041S- 2046S. 49 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references American Academy of Orthopaedic Surgeons and North American Spine Society. Clinical Guideline on Low Back Pain Phase 1 (First Contact Physician). 1996] 50 Carragee EJ, Alamin TF, Miller JL, Carragee JM. Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain. Spine J Jan-Feb;5(1): Linton SJ, Nordin E. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial. Spine Apr 15;31(8): Low Back Pain CIT Final Report January 2007 Page 16 of 37
18 The focus of preventing acute back pain from becoming chronic emphasizes practice of appropriate, evidence-based management, including not recommending bed rest, promoting exercise and smoking cessation, and preventing unnecessary imaging and unnecessary surgery. 52 The patient s emotional state and work-life issues can worsen the condition of acute back pain and should also be assessed as part of the treatment protocol. Recommendations: 1. Providers should assess all patients with low back pain for emotional status and work-life issues, provide reassurance to reduce fear and anxiety, and promote active self-management. 2. In the absence of red flag conditions, bed rest is not recommended and patients should be advised to remain active, returning to normal activity as soon as possible. 3. Patients with back pain who smoke should be assisted with smoking cessation. 4. Patients with low back pain should have assessment of functional status, using valid and reliable tests that are commonly available (such as the SF-36 Health Survey 53 ). Explanation: The CIT recognizes that emotional, social, and environmental factors play a large role in the prevention and improvement of back pain, 54 and that depression, 55 anxiety and sleep disruption have significant impact on patient health and response to therapy. While providers still need to rule out pathophysiologic causes of back pain, evaluations of emotional, social and environmental factors and functional status are crucial in preventing back pain recurrence, chronicity, and disability. 56 Tools for evaluating patients for the 52 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, Devilly, G.J. (2004). Assessment Devices. Accessed November 7, 2006, from Swinburne University, Clinical & Forensic Psychology Web site: 54 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Koes BW, van Tulder MW, et al. Clinical guidelines for the management of low back pain in primary care: An international comparison. Spine 2001;26: ; Loisel P, Buchnbinder R, et al. Prevention of work disability due to musculoskeletal disorders: the challenge of implementing the evidence. J Occu Rehab 2005;15(4): ] 55 Jarvik JG, Hollingworth W, Heagerty PJ, Haynor DR, Boyko EJ, Deyo RA. Three-year incidence of low back pain in an initially asymptomatic cohort: Clinical and imaging risk factors. Spine 2005;30: NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Beurskens AJ, De Vet HC, et al. Measuring the functional status of patients with low back pain: Assessment of the quality of four disease-specific questionnaires. Spine 1995;20: ; Delitto A. Are measures of function and disability important in low back care? Phys Ther 1994;74:52-62; Deyo Low Back Pain CIT Final Report January 2007 Page 17 of 37
19 presence of depression, emotional well-being, coping styles, and other work-life issues, are readily available and may help identify such barriers to improvement. These and other tools can also help caregivers evaluate patients abilities to do normal activities and at the same time help measure patients functional status and progress with treatment. One of the main reasons patients consult healthcare providers is for information and reassurance. 57 Patients need information to help them make informed, meaningful decisions about their care, to learn what to expect and what they can do. Educated patients have a better understanding of their treatment options and the likely outcome of each option, and a more balanced picture of the risks and benefits of these options. When given up-to-date information on a condition, the available options, and likely outcomes, patient perceptions are more likely to be realistic and patient satisfaction is more likely to improve. 58 Broadly focused educational approaches targeted to patients have limited value on their own. 59 The Institute for Clinical Systems Improvement (ICSI) has found that brochures which place an emphasis on reducing fear and anxiety and promoting active self-management have a greater opportunity for improving outcomes than traditional brochures that emphasize anatomy, ergonomics and specific back exercises. ICSI encourages health care professionals to have patient education materials and make them available throughout the community (including employers and local businesses). 60 Specific patient education content recommendations from ICSI include: 61 Absence of serious disease is likely when red flag conditions are not present. Hurt does not equal harm. There is a good prognosis for low back pain. The vast majority of patients experience significant improvements in four to six weeks. RA. Measuring the functional status of patients with low back pain. Arch Phys Med Rehabil : ] 57 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Von Korff M, Saunders K. The course of back pain in primary care. Spine 1996;21: ] 58 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references O Connor AM, Llewellyn-Thomas HA, Flodd AB. Modifying unwarranted variations in health care: Shared decision making using patient decision aids. Health Affairs 7 October 2004 web exclusive] 59 Deyo RA, Schall M, Berwick DM, Nolan T, Carver P. Continuous quality improvement for patients with back pain. J Gen Intern Med 2000;15: Institute for Clinical Systems Improvement. Healthcare guideline: Adult low back pain. 12 th edition, September Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. 61 Institute for Clinical Systems Improvement. Healthcare guideline: Adult low back pain. 12 th edition, September Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. Low Back Pain CIT Final Report January 2007 Page 18 of 37
20 Bed rest is not recommended and should be limited to no more than two days. Light activity will not further injure the spine and light activity typically helps speed recovery. A progressive resumption of work and activity levels leads to better short-term and long-term outcomes. Information and advice may be helpful regarding specific painful or limited activities, such as sitting, lifting, getting up from bed. An example of a back pain patient education hand-out used by Minnesota s Park Nicollet Health Services is provided on ICSI s website: 62 Several studies suggest that smoking is an independent risk factor for low back pain. 63 Other studies point out that smoking delays wound healing and that smokers have poorer clinical outcomes and longer recovery periods. 64 The reported health status of patients with spinal problems who smoke is significantly lower than that of those who do not smoke. 65 Therefore the CIT agreed that smoking cessation should be emphasized. Similarly, bed rest not only does not increase rate of recovery from low back pain but sometimes delays recovery 66 and may have adverse effects including increased stiffness, muscle wasting, loss of bone mineral density, pressure sores, and thrombosis. 67 Remaining active leads to more rapid recovery, less chronic disability, and recurring problems. 68 Patients should be encouraged to remain active and return to normal activity, though patients may temporarily modify their activity within their pain limits. 62 Institute for Clinical Systems Improvement. Patient Education Resources, Low Back Pain (by Park Nicollet Health Services) Accessed October 19, Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. 63 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Glassman SD, Rose SM, et al. The effect of post-operative nonsteroidal anti-inflammatory drug administration on spinal fusion. Spine 1998;23: ; Hadley MN, Reddy SV. Smoking and the human vertebral column: a review of the impact of cigarette use on vertebral bone metabolism and spinal fusion. Neurosurgery 1997;41: ] 65 NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Vogt MT, Hanscom B. Influence on smoking on the health status of spinal patients: The national spine network database. Spine 2002;27(3): ] 66 Deyo RA and Weinstein JN. Low back pain. N Engl J Med 2001;344(5): NCQA Spine Care Recognition Program Report Draft for Public Comment, May 2, [references Tulder van MW, Koes B. Musculoskeletal Disorders: Low back pain and sciatica (acute). Clin Evid 2004;12: ] 68 Institute for Clinical Systems Improvement. Healthcare guideline: Adult low back pain. 12 th edition, September Copyright 2006 by ICSI. Used with permission. ICSI retains all rights to the material. This material will in no way be used to determine provider compensation. Low Back Pain CIT Final Report January 2007 Page 19 of 37
21 VI. Review of Evidence-based Clinical Guidelines The Puget Sound Health Alliance is committed to promoting the use of evidence-based medicine in the Puget Sound region, and the team generally agreed that selecting and endorsing evidence-based guidelines for the primary management of low back pain was an important part of its work. It was agreed that there would be greater provider buy-in if the Alliance were to endorse welldefined treatment guidelines that focus on getting patients to resume normal activity as quickly as possible. A search of the National Guideline Clearinghouse 69 (NGC) for back pain guidelines found 218 related guidelines. Narrowing the NGC search to low back pain resulted in 157 related guidelines. Therefore the CIT was unable to review all guidelines. The team considered the adoption of the Agency for Health Care Policy and Research (AHCPR) clinical practice guidelines for management of acute low back pain in adults. 70 These are broadly known, general guidelines with established care pathways. However, they were published in 1994 and are no longer considered up-to-date for current medical practice. New treatments such as injections are not included and some of the terminology is outdated. Team members reviewed the AHCPR guidelines with the idea that they might be adapted and brought up-to-date for use by Alliance members. After considerable review it was concluded that significant work would be required to bring the guideline up-to-date. It was agreed that such extensive guideline development work was beyond the scope of the CIT and the Alliance. After lengthy discussion, the CIT chose not to endorse any specific set of guidelines, but rather to recommend that guidelines selected for use by providers be evidence-based, with the evidence graded as to quality and clearly referenced. The team reviewed the proposed NCQA Spine Care Recognition program for sub-acute and chronic back pain (released in draft form for public comment May 2006). The program comprises a set of measures, supported by the best available clinical evidence, promotes a model of care based on systematic patient assessment, patient education, limited use of imaging, and the use of surgery only after other options have been fully explored. The NCQA program does not endorse any one set of clinical guidelines and is open to physicians 69 National Guideline Clearinghouse, Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. Accessed online: October 13, Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline, Quick Reference Guide Number. 14. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, AHCPR Pub. No December Low Back Pain CIT Final Report January 2007 Page 20 of 37
Measure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization
Client HMSA: PQSR 2009 Measure Title X RAY PRIOR TO MRI OR CAT SCAN IN THE EVAULATION OF LOWER BACK PAIN Disease State Back pain Indicator Classification Utilization Strength of Recommendation Organizations
More informationSample Treatment Protocol
Sample Treatment Protocol 1 Adults with acute episode of LBP Definition: Acute episode Back pain lasting
More informationHealth Benchmarks Program Clinical Quality Indicator Specification 2013
Health Benchmarks Program Clinical Quality Indicator Specification 2013 Measure Title USE OF IMAGING STUDIES FOR LOW BACK PAIN Disease State Musculoskeletal Indicator Classification Utilization Strength
More informationCLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF LOW BACK PAIN
CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF LOW BACK PAIN Low back pain is very common, up to 90+% of people are affected by back pain at some time in their lives. Most often back pain is benign and
More informationPractice Guidelines For Low Back Pain
Consumers Guide Practice Guidelines For Low Back Pain Copyright 2008 American Chronic Pain Association Page 1 Written by: Penney Cowan Founder Executive Director American Chronic Pain Association Editors:
More informationLOW BACK INJURIES PROGRAM OF CARE PROGRAM OF CARE 4TH EDITION 2014
LOW BACK INJURIES PROGRAM OF CARE PROGRAM OF CARE 4TH EDITION 2014 GUIDE Acknowledgements Acknowledgements The WSIB would like to acknowledge the significant contributions of the following regulated Health
More informationMN Community Measurement Low Back Pain Measure Impact and Recommendation Document June 2010
MN Community Measurement Low Back Pain Measure Impact and Recommendation Document June 2010 Impact Relevance to Consumers, Employers and Payers Improvability Inclusiveness Mechanical low back pain (LBP)
More informationBACK PAIN MEASURES GROUP OVERVIEW
2014 PQRS OPTIONS F MEASURES GROUPS: BACK PAIN MEASURES GROUP OVERVIEW 2014 PQRS MEASURES IN BACK PAIN MEASURES GROUP: #148. Back Pain: Initial Visit #149. Back Pain: Physical Exam #150. Back Pain: Advice
More information6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.
High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty
More information.org. Herniated Disk in the Lower Back. Anatomy. Description
Herniated Disk in the Lower Back Page ( 1 ) Sometimes called a slipped or ruptured disk, a herniated disk most often occurs in your lower back. It is one of the most common causes of low back pain, as
More informationSpine University s Guide to Cauda Equina Syndrome
Spine University s Guide to Cauda Equina Syndrome 2 Introduction Your spine is a very complicated part of your body. It s made up of the bones (vertebrae) that keep it aligned, nerves that channel down
More informationWhite Paper: Reducing Utilization Concerns Regarding Spinal Fusion and Artificial Disc Implants
White Paper: Reducing Utilization Concerns Regarding Spinal Fusion and Artificial Disc Implants For Health Plans, Medical Management Organizations and TPAs Executive Summary Back pain is one of the most
More informationLow Back Injury in the Industrial Athlete: An Anatomic Approach
Low Back Injury in the Industrial Athlete: An Anatomic Approach Earl J. Craig, M.D. Assistant Professor Indiana University School of Medicine Department of Physical Medicine and Rehabilitation Epidemiology
More informationLow Back Pain Protocols
Low Back Pain Protocols Introduction: Diagnostic Triage And 1. Patient Group Adults aged 18 years and over with routine low back problems. Patients who have had recent surgery should be referred directly
More informationHitting a Nerve: The Triggers of Sciatica. Bruce Tranmer MD FRCS FACS
Hitting a Nerve: The Triggers of Sciatica Bruce Tranmer MD FRCS FACS Disclosures I have no financial disclosures Objectives - Sciatica Historical Perspective What is Sciatica What can cause Sciatica Clinical
More informationTemple Physical Therapy
Temple Physical Therapy A General Overview of Common Neck Injuries For current information on Temple Physical Therapy related news and for a healthy and safe return to work, sport and recreation Like Us
More informationDIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN. Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA
DIFFERENTIAL DIAGNOSIS OF LOW BACK PAIN Arnold J. Weil, M.D., M.B.A. Non-Surgical Orthopaedics, P.C. Atlanta, GA MEDICAL ALGORITHM OF REALITY LOWER BACK PAIN Yes Patient will never get better until case
More informationLumbar Disc Herniation/Bulge Protocol
Lumbar Disc Herniation/Bulge Protocol Anatomy and Biomechanics The lumbar spine is made up of 5 load transferring bones called vertebrae. They are stacked in a column with an intervertebral disc sandwiched
More informationLOW BACK PAIN; MECHANICAL
1 ORTHO 16 LOW BACK PAIN; MECHANICAL Background This case definition was developed by the Armed Forces Health Surveillance Center (AFHSC) for the purpose of epidemiological surveillance of a condition
More informationIntroduction: Anatomy of the spine and lower back:
Castleknock GAA club member and Chartered Physiotherapist, James Sherry MISCP, has prepared an informative article on the common causes of back pain and how best it can be treated. To book a physiotherapy
More informationGet Back to the Life You Love! The MedStar Spine Center in Chevy Chase
Get Back to the Life You Love! The MedStar Spine Center in Chevy Chase The MedStar Spine Center in Chevy Chase Relief from Pain, Restoration of Function Non-surgical, Minimally Invasive and Complex Surgical
More informationHerniated Cervical Disc
Herniated Cervical Disc North American Spine Society Public Education Series What Is a Herniated Disc? The backbone, or spine, is composed of a series of connected bones called vertebrae. The vertebrae
More informationHerniated Lumbar Disc
Herniated Lumbar Disc North American Spine Society Public Education Series What Is a Herniated Disc? The spine is made up of a series of connected bones called vertebrae. The disc is a combination of strong
More informationCervical Spondylosis (Arthritis of the Neck)
Copyright 2009 American Academy of Orthopaedic Surgeons Cervical Spondylosis (Arthritis of the Neck) Neck pain is extremely common. It can be caused by many things, and is most often related to getting
More informationHow To Cover Occupational Therapy
Guidelines for Medical Necessity Determination for Occupational Therapy These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine
More informationHow To Get An Mri Of The Lumbar Spine W/O Contrast
Date notice sent to all parties: May 27, 2014 IRO CASE #: ReviewTex, Inc. 1818 Mountjoy Drive San Antonio, TX 78232 (phone) 210-598-9381 (fax) 210-598-9382 reviewtex@hotmail.com Notice of Independent Review
More informationTreating Bulging Discs & Sciatica. Alexander Ching, MD
Treating Bulging Discs & Sciatica Alexander Ching, MD Disclosures Depuy Spine Teaching and courses K2 Spine Complex Spine Study Group Disclosures Take 2 I am a spine surgeon I like spine surgery I believe
More informationThere are four main regions of the back; the cervical (C), thoracic (T), lumbar (L), and sacral (S) regions
Low Back Pain Overview Low back pain is one of the most common disorders in the United States. About 80 percent of people have at least one episode of low back pain during their lifetime. Factors that
More informationSciatica Yuliya Mutsa PTA 236
Sciatica Yuliya Mutsa PTA 236 Sciatica is a common type of pain affecting the sciatic nerve, which extends from the lower back all the way through the back of the thigh and down through the leg. Depending
More informationAdvanced Practice Provider Academy
(+)Dean T. Harrison, MPAS,PA C,DFAAPA Director of Mid Level Practitioners; Assistant Medical Director Clinical Evaluation Unit, Division of Emergency Medicine, Department of Surgery, Duke University Medical
More informationClinical guidance for MRI referral
MRI for cervical radiculopathy Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of spine for a patient 16 years or older for suspected: cervical radiculopathy
More informationBack & Neck Pain Survival Guide
Back & Neck Pain Survival Guide www.kleinpeterpt.com Zachary - 225-658-7751 Baton Rouge - 225-768-7676 Kleinpeter Physical Therapy - Spine Care Program Finally! A Proven Assessment & Treatment Program
More informationBrought to you by the SunAssociation
Brought to you by the SunAssociation Low Back Pain by Elizabeth Smoots, MD Definition Low back pain is an ache or discomfort in the area of the lower part of the back and spinal column. The lower spinal
More informationThe Spine Center at Beth Israel Deaconess
Spinal Pain The Spine Center at Beth Israel Deaconess Medical Center developed the following detailed eplanation of our care pathways for primary care providers to help support your interactions with patients
More informationX Stop Spinal Stenosis Decompression
X Stop Spinal Stenosis Decompression Am I a candidate for X Stop spinal surgery? You may be a candidate for the X Stop spinal surgery if you have primarily leg pain rather than mostly back pain and your
More informationHerniated Disk in the Lower Back
Nader M. Hebela, MD Fellow of the American Academy of Orthopaedic Surgeons http://orthodoc.aaos.org/hebela Cleveland Clinic Abu Dhabi Cleveland Clinic Abu Dhabi Neurological Institute Al Maryah Island
More informationTHE MEDICAL TREATMENT GUIDELINES
THE MEDICAL TREATMENT GUIDELINES I. INTRODUCTION A. About the Medical Treatment Guidelines. On December 1, 2010, the NYS Workers' Compensation Board is implementing new regulations and Medical Treatment
More informationLUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B LUMBAR. Hips R L B R L B
1 Patient Name In order to properly assess your condition, we must understand how much your BACK/LEG (SCIATIC) PAIN has affected your ability to manage everyday activities. For each item below, please
More informationDiagnosis and Management for Chronic Back Pain: Critical for your Recovery
Diagnosis and Management for Chronic Back Pain: Critical for your Recovery Dr. Connie D Astolfo, DC, PhD (candidate) In past articles I have stressed that the causes of back pain can be very complex. This
More informationNeck Pain Frequently Asked Questions. Moe R. Lim, MD UNC Orthopaedics (919-96B-ONES) UNC Spine Center (919-957-6789)
Neck Pain Frequently Asked Questions Moe R. Lim, MD UNC Orthopaedics (919-96B-ONES) UNC Spine Center (919-957-6789) Neck Pain Human Spine 25 bones Cervical (7) Thoracic (12) Lumbar (5) Sacrum Human Spine
More informationBACK PAIN PATHWAY DEFINTIONS
BACK PAIN PATHWAY DEFINTIONS Cauda Equina Syndrome (CES) Current or imminent compression of the sacral nerve roots resulting in neurogenic bladder and bowel dysfunction. Symptoms typically include: severe
More informationPatient Guide to Lower Back Surgery
The following is a sampling of products offered by Zimmer Spine for use in Open Lumbar Fusion procedures. Patient Guide to Lower Back Surgery Open Lumbar Fusion Dynesys The Dynesys Dynamic Stabilization
More informationAcute Low Back Pain. North American Spine Society Public Education Series
Acute Low Back Pain North American Spine Society Public Education Series What Is Acute Low Back Pain? Acute low back pain (LBP) is defined as low back pain present for up to six weeks. It may be experienced
More informationSpinal Surgery 2. Teaching Aims. Common Spinal Pathologies. Disc Degeneration. Disc Degeneration. Causes of LBP 8/2/13. Common Spinal Conditions
Teaching Aims Spinal Surgery 2 Mr Mushtaque A. Ishaque BSc(Hons) BChir(Cantab) DM FRCS FRCS(Ed) FRCS(Orth) Hunterian Professor at The Royal College of Surgeons of England Consultant Orthopaedic Spinal
More informationOptions for Cervical Disc Degeneration A Guide to the Fusion Arm of the M6 -C Artificial Disc Study
Options for Cervical Disc Degeneration A Guide to the Fusion Arm of the M6 -C Artificial Disc Study Each year, hundreds of thousands of adults are diagnosed with Cervical Disc Degeneration, an upper spine
More informationClinical Guideline. Low Back Pain Orthopaedics. Princess Alexandra Hospital Emergency Department. 1 Purpose. 2 Background
Princess Alexandra Hospital Emergency Department Clinical Guideline Orthopaedics Review Officer: Katherine Isoardi Version no: 1 Approval date: 18/03/2015 Review date: 18/03/2017 Approving Officer Dr James
More informationLumbar Laminectomy and Interspinous Process Fusion
Lumbar Laminectomy and Interspinous Process Fusion Introduction Low back and leg pain caused by pinched nerves in the back is a common condition that limits your ability to move, walk, and work. This condition
More informationOrthopaedic Approaches to Chronic Neck and Lower Back Pain
Orthopaedic Approaches to Chronic Neck and Lower Back Pain David C. Urquia, MD Augusta Orthopaedic Associates / Waterville Orthopedics Introduction We see many patients who have longstanding pain in the
More informationLower Back Pain. Introduction. Anatomy
Lower Back Pain Introduction Back pain is the number one problem facing the workforce in the United States today. To illustrate just how big a problem low back pain is, consider these facts: Low back pain
More informationNeck Pain & Cervicogenic Headache Integrating Research into Practice: San Luis Sports Therapy s Approach to Evidence-Based Practice
Neck Pain & Cervicogenic Headache Integrating Research into Practice: San Luis Sports Therapy s Approach to Evidence-Based Practice PROBLEM: Neck Pain and Cervicogenic Headache 66% Proportion of individuals
More informationLumbar Spinal Stenosis
Lumbar Spinal Stenosis North American Spine Society Public Education Series What Is Lumbar Spinal Stenosis? The vertebrae are the bones that make up the lumbar spine (low back). The spinal canal runs through
More informationBACK PAIN: WHAT YOU SHOULD KNOW
BACK PAIN: WHAT YOU SHOULD KNOW Diane Metzer LOWER BACK PAIN Nearly everyone at some point has back pain that interferes with work, recreation and routine daily activities. Four out of five adults experience
More information.org. Fractures of the Thoracic and Lumbar Spine. Cause. Description
Fractures of the Thoracic and Lumbar Spine Page ( 1 ) Spinal fractures can vary widely in severity. While some fractures are very serious injuries that require emergency treatment, other fractures can
More informationSPINE ANATOMY AND PROCEDURES. Tulsa Spine & Specialty Hospital 6901 S. Olympia Avenue Tulsa, Oklahoma 74132
SPINE ANATOMY AND PROCEDURES Tulsa Spine & Specialty Hospital 6901 S. Olympia Avenue Tulsa, Oklahoma 74132 SPINE ANATOMY The spine consists of 33 bones called vertebrae. The top 7 are cervical, or neck
More informationHerniated Disk. This reference summary explains herniated disks. It discusses symptoms and causes of the condition, as well as treatment options.
Herniated Disk Introduction Your backbone, or spine, has 24 moveable vertebrae made of bone. Between the bones are soft disks filled with a jelly-like substance. These disks cushion the vertebrae and keep
More informationDocument Author: Frances Hunt Date 03/03/2008. 1. Purpose of this document To standardise the treatment of whiplash associated disorder.
Guideline Title: WHIPLASH ASSOCIATED DISORDER Document Author: Frances Hunt Date 03/03/2008 Ratified by: Frances Hunt, Head of Physiotherapy Date: 16.09.15 Review date: 16.09.17 Links to policies: All
More informationChronic Low Back Pain
Chronic Low Back Pain North American Spine Society Public Education Series What is Chronic Pain? Low back pain is considered to be chronic if it has been present for longer than three months. Chronic low
More informationOpen Discectomy. North American Spine Society Public Education Series
Open Discectomy North American Spine Society Public Education Series What Is Open Discectomy? Open discectomy is the most common surgical treatment for ruptured or herniated discs of the lumbar spine.
More informationInformation for the Patient About Surgical
Information for the Patient About Surgical Decompression and Stabilization of the Spine Aging and the Spine Daily wear and tear, along with disc degeneration due to aging and injury, are common causes
More informationNerve Root Pain. Your back pain diagnosis. Contact Details. Spinal Triage Nuffield Orthopaedic Centre Windmill Road Headington Oxford OX3 7LD
Nerve Root Pain Contact Details Spinal Triage Nuffield Orthopaedic Centre Windmill Road Headington Oxford OX3 7LD Phone: 01865 738051 Fax: 01865 738027 Web Site www.noc.nhs.uk Nerve Pain Patient Information
More informationTHE LUMBAR SPINE (BACK)
THE LUMBAR SPINE (BACK) At a glance Chronic back pain, especially in the area of the lumbar spine (lower back), is a widespread condition. It can be assumed that 75 % of all people have it sometimes or
More informationLow Back Pain (LBP) Prevalence. Low Back Pain (LBP) Prevalence. Lumbar Fusion: Where is the Evidence?
15 th Annual Cleveland Clinic Pain Management Symposium Sarasota, Florida Lumbar Fusion: Where is the Evidence? Gordon R. Bell, M.D. Director, Cleveland Clinic Low Back Pain (LBP) Prevalence Lifetime prevalence:
More information.org. Cervical Spondylosis (Arthritis of the Neck) Anatomy. Cause
Cervical Spondylosis (Arthritis of the Neck) Page ( 1 ) Neck pain can be caused by many things but is most often related to getting older. Like the rest of the body, the disks and joints in the neck (cervical
More information.org. Cervical Radiculopathy (Pinched Nerve) Anatomy. Cause
Cervical Radiculopathy (Pinched Nerve) Page ( 1 ) Cervical radiculopathy, commonly called a pinched nerve occurs when a nerve in the neck is compressed or irritated where it branches away from the spinal
More informationThe Newest Breakthrough In Non- Surgical Treatment of Herniated or Degenerative Discs
The Newest Breakthrough In Non- Surgical Treatment of Herniated or Degenerative Discs The DRX 9000 is Your Answer To Persistent Back Pain To People Who Want To Be Rid Of Lower Back Pain But Think They
More informationThe Lewin Group undertook the following steps to identify the guidelines relevant to the 11 targeted procedures:
Guidelines The following is a list of proposed medical specialty guidelines that have been found for the 11 targeted procedures to be included in the Medicare Imaging Demonstration. The list includes only
More informationDoes the pain radiating down your legs, buttocks or lower back prevent you from walking long distances?
Does the pain radiating down your legs, buttocks or lower back prevent you from walking long distances? Do you experience weakness, tingling, numbness, stiffness, or cramping in your legs, buttocks or
More informationLumbar Spinal Stenosis
Copyright 2009 American Academy of Orthopaedic Surgeons Lumbar Spinal Stenosis Almost everyone will experience low back pain at some point in their lives. A common cause of low back pain is lumbar spinal
More informationSeven Myths About Back Pain
Seven Myths About Back Pain As reported in Safety Bulletin BCL004, Lifting and Your Back Some Fresh Ideas, up to 80 per cent of adults will experience back pain at some time during their lives. Let s take
More information1 REVISOR 5223.0070. (4) Pain associated with rigidity (loss of motion or postural abnormality) or
1 REVISOR 5223.0070 5223.0070 MUSCULOSKELETAL SCHEDULE; BACK. Subpart 1. Lumbar spine. The spine rating is inclusive of leg symptoms except for gross motor weakness, bladder or bowel dysfunction, or sexual
More informationStandard of Care: Cervical Radiculopathy
Department of Rehabilitation Services Physical Therapy Diagnosis: Cervical radiculopathy, injury to one or more nerve roots, has multiple presentations. Symptoms may include pain in the cervical spine
More informationInternational Postprofessional Doctoral of Physical Therapy (DPT) in Musculoskeletal Management Program (non US/Canada) Curriculum
International Postprofessional Doctoral of Physical Therapy (DPT) in Musculoskeletal Management Program (non US/Canada) Curriculum Effective: July 2015 INTERNATIONAL POSTPROFESSIONAL DOCTORAL OF PHYSICAL
More informationSpinal Surgery Functional Status and Quality of Life Outcome Specifications 2015 (01/01/2013 to 12/31/2013 Dates of Procedure) September 2014
Description Methodology For patients ages 18 years and older who undergo a lumbar discectomy/laminotomy or lumbar spinal fusion procedure during the measurement year, the following measures will be calculated:
More informationEach year, hundreds of thousands of adults are diagnosed with Cervical Disc Degeneration, The Cervical Spine. What is the Cervical Spine?
Each year, hundreds of thousands of adults are diagnosed with Cervical Disc Degeneration, an upper spine condition that can cause pain and numbness in the neck, shoulders, arms, and even hands. This patient
More informationWhiplash and Whiplash- Associated Disorders
Whiplash and Whiplash- Associated Disorders North American Spine Society Public Education Series What Is Whiplash? The term whiplash might be confusing because it describes both a mechanism of injury and
More informationImaging degenerative disk disease in the lumbar spine. Elaine Besancon MS III Dr. Gillian Lieberman
Imaging degenerative disk disease in the lumbar spine Elaine Besancon MS III Dr. Gillian Lieberman Learning Objectives Anatomy review Pathophysiology of degenerative disc disease Common sequelae of disk
More informationNonoperative Management of Herniated Cervical Intervertebral Disc With Radiculopathy. Spine Volume 21(16) August 15, 1996, pp 1877-1883
Nonoperative Management of Herniated Cervical Intervertebral Disc With Radiculopathy 1 Spine Volume 21(16) August 15, 1996, pp 1877-1883 Saal, Joel S. MD; Saal, Jeffrey A. MD; Yurth, Elizabeth F. MD FROM
More informationAcute low back pain. Key reviewers: Mr Chris Hoffman, Orthopaedic Surgeon, Mana Orthopaedics, Wellington
Acute low back pain Key reviewers: Mr Chris Hoffman, Orthopaedic Surgeon, Mana Orthopaedics, Wellington Dr John MacVicar, Medical Director, Southern Rehab, Christchurch Key concepts: Acute low back pain
More informationNeck Pain Overview Causes, Diagnosis and Treatment Options
Neck Pain Overview Causes, Diagnosis and Treatment Options Neck pain is one of the most common forms of pain for which people seek treatment. Most individuals experience neck pain at some point during
More informationChoosing Wisely Recommendation Analysis: Prioritizing Opportunities for Reducing Inappropriate Care
Choosing Wisely Recommendation Analysis: Prioritizing Opportunities for Reducing Inappropriate Care IMAGING FOR NONSPECIFIC LOW BACK PAIN Sarah Jane Reed, MSc and Steven Pearson, MD, MSc INSTITUTE FOR
More informationINFORMATION FOR YOU. Lower Back Pain
INFORMATION FOR YOU Lower Back Pain WHAT IS ACUTE LOWER BACK PAIN? Acute lower back pain is defined as low back pain present for up to six weeks. It may be experienced as aching, burning, stabbing, sharp
More informationTABLE OF CONTENTS Page
TABLE OF CONTENTS Page INTRODUCTION 3 CONCLUSIONS AND RECOMMENDATIONS 5 EVALUATION AND TREATMENT OF ACUTE LOW BACK PROBLEMS IN ADULTS 9 SPECIAL STUDIES IN DIAGNOSTIC CONSIDERATIONS 15 PSYCHOLOGICAL RISK
More informationSTATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION
In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX Petitioner
More informationSPINE PATIENT HISTORY FORM
Trenton Orthopaedic Group 116 Washington Crossing Road 1225 Whitehorse-Mercerville Road Pennington, NJ 08534 Bldg. D., Suite 220 Mercerville, NJ 08619 22-1897695 SPINE PATIENT HISTORY FORM Please print
More informationSpinal Injections. North American Spine Society Public Education Series
Spinal Injections North American Spine Society Public Education Series What Is a Spinal Injection? Your doctor has suggested that you have a spinal injection to help reduce pain and improve function. This
More informationSurgery for cervical disc prolapse or cervical osteophyte
Mr Paul S. D Urso MBBS(Hons), PhD, FRACS Neurosurgeon Provider Nº: 081161DY Epworth Centre Suite 6.1 32 Erin Street Richmond 3121 Tel: 03 9421 5844 Fax: 03 9421 4186 AH: 03 9483 4040 email: paul@pauldurso.com
More informationMusculoskeletal: Acute Lower Back Pain
Musculoskeletal: Acute Lower Back Pain Acute Lower Back Pain Back Pain only Sciatica / Radiculopathy Possible Cord or Cauda Equina Compression Possible Spinal Canal Stenosis Red Flags Initial conservative
More informationLow Back Pain: Utilization of Health Care Services in Oregon Oregon Health Care Quality Corporation Report March 2013
Low Back Pain: Utilization of Health Care Services in Oregon Oregon Health Care Quality Corporation Report March 2013 520 SW Sixth Avenue Suite 830, Portland, Oregon 97204 Phone 503.241.3571 Fax 503.972.0822
More informationMANAGING BACK PAIN GETTING YOU BACK INTO ACTION MANAGING BACK PAIN. www.healthcare-rm.com
H E A L T H R I S K M A N A G E M E N T MANAGING BACK PAIN MANAGING BACK PAIN GETTING YOU BACK INTO ACTION GETTING YOU BACK INTO ACTION www.healthcare-rm.com Who is this for? CONTENTS Introduction about
More informationSpine Trauma: When to Transfer. Alexander Ching, MD Director, Orthopaedic Spine Trauma OHSU
Spine Trauma: When to Transfer Alexander Ching, MD Director, Orthopaedic Spine Trauma OHSU Disclosures Depuy Spine Consultant (teaching and courses) Department education and research funds Atlas Spine
More informationPrevalence of Back Pain
Prevalence of Back Pain Point prevalence 12-35% Lifetime prevalence 49-80% Annual prevalence in UK (OPCS surveys 1997) 37% (3.5 million/year) Male=female No regional differences Increases with age Prevalent
More informationBiomechanical Basis of Lumbar Pain. Prepared by S. Pollak. Introduction:
Biomechanical Basis of Lumbar Pain Prepared by S. Pollak Introduction: The lumbar area of the back is made up of five movable L1-L5 vertebrae which have intervertebral discs in between them 1. The intervertebral
More informationManagement of spinal cord compression
Management of spinal cord compression (SUMMARY) Main points a) On diagnosis, all patients should receive dexamethasone 10mg IV one dose, then 4mg every 6h. then switched to oral dose and tapered as tolerated
More informationVCA Animal Specialty Group 5610 Kearny Mesa Rd., Suite B San Diego, CA 92111 858-560-8006 www.vcaanimalspecialtygroup.com.
Disk Disease While not limited to small breeds, disc disease is much more prevalent among Dachshunds, Lhasa Apsos, Poodles, Beagles and Pekingese primarily due to genetic factors. These traits result in
More informationRehabilitation Where You Recover. Inpatient Rehabilitation Services at Albany Medical Center
Rehabilitation Where You Recover Inpatient Rehabilitation Services at Albany Medical Center You're Here and So Are We As the region s only academic medical center, Albany Medical Center offers a number
More informationPatient Information. Lumbar Spine Segmental Decompression. Royal Devon and Exeter NHS Foundation Trust
Lumbar Spine Segmental Decompression Royal Devon and Exeter NHS Foundation Trust Patient Information Lumbar Spine Segmental Decompression Reference Number: TO 05 004 004 (version date: June 2015) Introduction
More informationPhysiotherapy fees and utilization guidelines for auto insurance accident claimants
No. A-12/97 Property & Casualty ) Auto Physiotherapy fees and utilization guidelines for auto insurance accident claimants To the attention of all insurance companies licensed to transact automobile insurance
More informationIf you or a loved one have suffered because of a negligent error during spinal surgery, you will be going through a difficult time.
If you or a loved one have suffered because of a negligent error during spinal surgery, you will be going through a difficult time. You may be worried about your future, both in respect of finances and
More information